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CITY OF TIGARD Plumbing Application Recd B
4 . 31 25 SW:HALL BLVD. Commercial and Residential Date Recd r 0
:' IGARD, OR 97223 Date to P E
Date tST
:503) 639 -4171
Permit d O r Lt•l-r - of 1
Print or Type Related SWR 297
Incomplete or illegible applications will not be accepted Called t4 7
�1me
ot Cevel m Pr ect FIXTURES (Individual) QTY PRICE AMT
Job I tv ab- } � ot
/ .. - S
/ 9.00
t dress site
Lavatory d
Address �j / 9 00
S.. e
` 1/ 7i( 446 4 � / b rub or Tuo/Shower Como 9 00
State A 40 p • ip Shower Only 9.00
• Nam
ff 7.0 0-0,--,1- Water Closet 9.00 1/�� r� r�11
D�snwasner
p / q
I 9.00 I
' Owner M h ng Address ..Ip4 Sui te Garoage Disposal
1 9 00
of Washing Machine 9.00
C. tats Lo Phone Floor Drain h 2
vi 9�zzz 9 00
Name a
1 9.00
I t .(� p oc c. e o- 9.00
• Occupant Mailing Address Q /� ` Suite Water Heater /
i p /l < Q sf �, . , e C 2 l0 Laundry Room Tray 9.00
G ate Ziff �� Phone Unnal
4?-- I 9.00
Other Fixtures ISoeufy► 9.00
`/ R
1,-t G. I 9.00
Contractor Mailing Address. Suite
34 3o St- _se? IC
I 9.00
IPnor to issuance C . /D � ,ry/rSt Phone
1 9.00
applicant must 4 _ eA 770o 9 oO stZ 7771( I 9.00
' provide ad Oregon Const. Cont. Board Lhc.s Exp Date I 9.00
tantracors '7,2,4 r a 9.00
license Plumbing Lic. tf Exp. Date Sewer - 1st 100' 30.00
information v 4 -02./ 9 )36
for COT COT Business Tax or Metro * Exp. Date Sewer -each additional 100' 25.00
database). Water Service - 1st 100' 30.00
Name p � 'i later Service - each aaaitionah 200' 25.00
Architect 2 1 - 760 1 Storm & Rain Drain - 1st 100' 30.00
Or Mailing Address I Suite / Storm & Raul Drain - each additional 100' 25.00
Mobile Home Space 25.00
Engineer Cary /State Zip Phone Commerce' Back Flow Prevention Device or Anti- 25.00
Pollution Device
2esc ^be .vont New .? Addition C Alteration Recahr C Residential Bacxftcw crevennon Device' 15.00
to ce cone: Residential O Non-residential /tom Any Trap or 'Waste Nct Connected to a Fixture
A cdit:onal aescnotton of wcrx
/ /// ( n 5 v� I 9.00
`ate Catch Basin � 9 00 • • C IC_ 94' J, insp. or Existing r umoing 40.00
e 1"-r. Special Requested per0hr
7 ustmg use of h equested Inspections 40.00
..Icing or property 1 oerhr
Rain Drain. single family dwelling 30.00
:dosed use of I Grease Traps I 9.00 •
.,tcirg or property
■
QUANTITY TOTAL I
re you cawing moving or replacing any fixtures? Yes 0 No ] lso+rerrc x use _:agram •s euired i Cuanrry •s > ?
if yes see back of form) 'SUBTOTAL I 2 flJ (/ .a
• - ereoy acknowledge that I nave read this application, that the information
-en is correct. that I am the owner or authonzed agent of the owner. and 5% SURCHARGE
at clans submt are omolian - with Oregon State Laws. 4
5 gnature o her /Agent PLAN REVIEW 25% OF SUBTOTAL
4r I Date
?ecurea
/_ - ^ =ntv 15 xhae r y at :s > _ ?
nt3ct Nam=
( - Phone 7 TOTAL I / �� ,\
/ _ I 'Minimum permit fee is 525 - 5% surcharge. except Residential Backflow
Lc S 6'1( 2 7 Prevention Device. wncca is 515 - 5% surcharge
i:'.dsts'.olmapp.doc 3/96
'LEASE COMPLETE AS APPROPRIATE TO PROJECT:
ci
I Fixtures to be capped, moved or replaced I Qty I
Sink
I Lavatory
' Tub or Tub /Shower Combination
Shower Only
Water Closet
Dishwasher
Garbage Disposal
Washing Machine
Floor Drain 2"
3"
4 "
Water Heater
Laundry Room Tray
Urinal
Other Fixtures (Specify)
;OMMENTS REGARDING ABOVE: